[Congressional Bills 104th Congress]
[From the U.S. Government Publishing Office]
[S. 1044 Engrossed in Senate (ES)]

  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
104th CONGRESS
  2d Session
                                S. 1044

_______________________________________________________________________

                                 AN ACT


 
To amend title III of the Public Health Service Act to consolidate and 
   reauthorize provisions relating to health centers, and for other 
                               purposes.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Health Centers Consolidation Act of 
1996''.

SEC. 2. CONSOLIDATION AND REAUTHORIZATION OF PROVISIONS.

    Subpart I of part D of title III of the Public Health Service Act 
(42 U.S.C. 254b et seq.) is amended to read as follows:

                      ``Subpart I--Health Centers

``SEC. 330. HEALTH CENTERS.

    ``(a) Definition of Health Center.--
            ``(1) In general.--For purposes of this section, the term 
        `health center' means an entity that serves a population that 
        is medically underserved, or a special medically underserved 
        population comprised of migratory and seasonal agricultural 
        workers, the homeless, and residents of public housing, by 
        providing, either through the staff and supporting resources of 
        the center or through contracts or cooperative arrangements--
                    ``(A) required primary health services (as defined 
                in subsection (b)(1)); and
                    ``(B) as may be appropriate for particular centers, 
                additional health services (as defined in subsection 
                (b)(2)) necessary for the adequate support of the 
                primary health services required under subparagraph 
                (A);
        for all residents of the area served by the center (hereafter 
        referred to in this section as the `catchment area').
            ``(2) Limitation.--The requirement in paragraph (1) to 
        provide services for all residents within a catchment area 
        shall not apply in the case of a health center receiving a 
        grant only under subsection (g), (h), or (i).
    ``(b) Definitions.--For purposes of this section:
            ``(1) Required primary health services.--
                    ``(A) In general.--The term `required primary 
                health services' means--
                            ``(i) basic health services which, for 
                        purposes of this section, shall consist of--
                                    ``(I) health services related to 
                                family medicine, internal medicine, 
                                pediatrics, obstetrics, or gynecology 
                                that are furnished by physicians and 
                                where appropriate, physician 
                                assistants, nurse practitioners, and 
                                nurse midwives;
                                    ``(II) diagnostic laboratory and 
                                radiologic services;
                                    ``(III) preventive health services, 
                                including--
                                            ``(aa) prenatal and 
                                        perinatal services;
                                            ``(bb) screening for breast 
                                        and cervical cancer;
                                            ``(cc) well-child services;
                                            ``(dd) immunizations 
                                        against vaccine-preventable 
                                        diseases;
                                            ``(ee) screenings for 
                                        elevated blood lead levels, 
                                        communicable diseases, and 
                                        cholesterol;
                                            ``(ff) pediatric eye, ear, 
                                        and dental screenings to 
                                        determine the need for vision 
                                        and hearing correction and 
                                        dental care;
                                            ``(gg) voluntary family 
                                        planning services; and
                                            ``(hh) preventive dental 
                                        services;
                                    ``(IV) emergency medical services; 
                                and
                                    ``(V) pharmaceutical services as 
                                may be appropriate for particular 
                                centers;
                            ``(ii) referrals to providers of medical 
                        services and other health-related services 
                        (including substance abuse and mental health 
                        services);
                            ``(iii) patient case management services 
                        (including counseling, referral, and follow-up 
                        services) and other services designed to assist 
                        health center patients in establishing 
                        eligibility for and gaining access to Federal, 
                        State, and local programs that provide or 
                        financially support the provision of medical, 
                        social, educational, or other related services;
                            ``(iv) services that enable individuals to 
                        use the services of the health center 
                        (including outreach and transportation services 
                        and, if a substantial number of the individuals 
                        in the population served by a center are of 
                        limited English-speaking ability, the services 
                        of appropriate personnel fluent in the language 
                        spoken by a predominant number of such 
                        individuals); and
                            ``(v) education of patients and the general 
                        population served by the health center 
                        regarding the availability and proper use of 
                        health services.
                    ``(B) Exception.--With respect to a health center 
                that receives a grant only under subsection (g), the 
                Secretary, upon a showing of good cause, shall--
                            ``(i) waive the requirement that the center 
                        provide all required primary health services 
                        under this paragraph; and
                            ``(ii) approve, as appropriate, the 
                        provision of certain required primary health 
                        services only during certain periods of the 
                        year.
            ``(2) Additional health services.--The term `additional 
        health services' means services that are not included as 
        required primary health services and that are appropriate to 
        meet the health needs of the population served by the health 
        center involved. Such term may include--
                    ``(A) environmental health services, including--
                            ``(i) the detection and alleviation of 
                        unhealthful conditions associated with water 
                        supply;
                            ``(ii) sewage treatment;
                            ``(iii) solid waste disposal;
                            ``(iv) rodent and parasitic infestation;
                            ``(v) field sanitation;
                            ``(vi) housing; and
                            ``(vii) other environmental factors related 
                        to health; and
                    ``(B) in the case of health centers receiving 
                grants under subsection (g), special occupation-related 
                health services for migratory and seasonal agricultural 
                workers, including--
                            ``(i) screening for and control of 
                        infectious diseases, including parasitic 
                        diseases; and
                            ``(ii) injury prevention programs, 
                        including prevention of exposure to unsafe 
                        levels of agricultural chemicals including 
                        pesticides.
            ``(3) Medically underserved populations.--
                    ``(A) In general.--The term `medically underserved 
                population' means the population of an urban or rural 
                area designated by the Secretary as an area with a 
                shortage of personal health services or a population 
                group designated by the Secretary as having a shortage 
                of such services.
                    ``(B) Criteria.--In carrying out subparagraph (A), 
                the Secretary shall prescribe criteria for determining 
                the specific shortages of personal health services of 
                an area or population group. Such criteria shall--
                            ``(i) take into account comments received 
                        by the Secretary from the chief executive 
                        officer of a State and local officials in a 
                        State; and
                            ``(ii) include factors indicative of the 
                        health status of a population group or 
                        residents of an area, the ability of the 
                        residents of an area or of a population group 
                        to pay for health services and their 
                        accessibility to them, and the availability of 
                        health professionals to residents of an area or 
                        to a population group.
                    ``(C) Limitation.--The Secretary may not designate 
                a medically underserved population in a State or 
                terminate the designation of such a population unless, 
                prior to such designation or termination, the Secretary 
                provides reasonable notice and opportunity for comment 
                and consults with--
                            ``(i) the chief executive officer of such 
                        State;
                            ``(ii) local officials in such State; and
                            ``(iii) the organization, if any, which 
                        represents a majority of health centers in such 
                        State.
                    ``(D) Permissible designation.--The Secretary may 
                designate a medically underserved population that does 
                not meet the criteria established under subparagraph 
                (B) if the chief executive officer of the State in 
                which such population is located and local officials of 
                such State recommend the designation of such population 
                based on unusual local conditions which are a barrier 
                to access to or the availability of personal health 
                services.
    ``(c) Planning Grants.--
            ``(1) In general.--
                    ``(A) Centers.--The Secretary may make grants to 
                public and nonprofit private entities for projects to 
                plan and develop health centers which will serve 
                medically underserved populations. A project for which 
                a grant may be made under this subsection may include 
                the cost of the acquisition and lease of buildings and 
                equipment (including the costs of amortizing the 
                principal of, and paying the interest on, loans) and 
                shall include--
                            ``(i) an assessment of the need that the 
                        population proposed to be served by the health 
                        center for which the project is undertaken has 
                        for required primary health services and 
                        additional health services;
                            ``(ii) the design of a health center 
                        program for such population based on such 
                        assessment;
                            ``(iii) efforts to secure, within the 
                        proposed catchment area of such center, 
                        financial and professional assistance and 
                        support for the project;
                            ``(iv) initiation and encouragement of 
                        continuing community involvement in the 
                        development and operation of the project; and
                            ``(v) proposed linkages between the center 
                        and other appropriate provider entities, such 
                        as health departments, local hospitals, and 
                        rural health clinics, to provide better 
                        coordinated, higher quality, and more cost-
                        effective health care services.
                    ``(B) Comprehensive service delivery networks and 
                plans.--The Secretary may make grants to health centers 
                that receive assistance under this section to enable 
                the centers to plan and develop a network or plan for 
                the provision of health services, which may include the 
                provision of health services on a prepaid basis or 
                through another managed care arrangement, to some or to 
                all of the individuals which the centers serve. Such a 
                grant may only be made for such a center if--
                            ``(i) the center has received grants under 
                        subsection (e)(1)(A) for at least 2 consecutive 
                        years preceding the year of the grant under 
                        this subparagraph or has otherwise 
                        demonstrated, as required by the Secretary, 
                        that such center has been providing primary 
                        care services for at least the 2 consecutive 
                        years immediately preceding such year; and
                            ``(ii) the center provides assurances 
                        satisfactory to the Secretary that the 
                        provision of such services on a prepaid basis, 
                        or under another managed care arrangement, will 
                        not result in the diminution of the level or 
                        quality of health services provided to the 
                        medically underserved population served prior 
                        to the grant under this subparagraph.
                Any such grant may include the acquisition and lease of 
                buildings and equipment which may include data and 
                information systems (including the costs of amortizing 
                the principal of, and paying the interest on, loans), 
                and providing training and technical assistance related 
                to the provision of health services on a prepaid basis 
                or under another managed care arrangement, and for 
                other purposes that promote the development of managed 
                care networks and plans.
            ``(2) Limitation.--Not more than two grants may be made 
        under this subsection for the same project, except that upon a 
        showing of good cause, the Secretary may make additional grant 
        awards.
    ``(d) Managed Care Loan Guarantee Program.--
            ``(1) Establishment.--
                    ``(A) In general.--The Secretary shall establish a 
                program under which the Secretary may, in accordance 
                with this subsection and to the extent that 
                appropriations are provided in advance for such 
                program, guarantee the principal and interest on loans 
                made by non-Federal lenders to health centers funded 
                under this section for the costs of developing and 
                operating managed care networks or plans.
                    ``(B) Use of funds.--Loan funds guaranteed under 
                this subsection may be used--
                            ``(i) to establish reserves for the 
                        furnishing of services on a pre-paid basis; or
                            ``(ii) for costs incurred by the center or 
                        centers, otherwise permitted under this 
                        section, as the Secretary determines are 
                        necessary to enable a center or centers to 
                        develop, operate, and own the network or plan.
                    ``(C) Publication of guidance.--Prior to 
                considering an application submitted under this 
                subsection, the Secretary shall publish guidelines to 
                provide guidance on the implementation of this section. 
                The Secretary shall make such guidelines available to 
                the universe of parties affected under this subsection, 
                distribute such guidelines to such parties upon the 
                request of such parties, and provide a copy of such 
                guidelines to the appropriate committees of Congress.
            ``(2) Protection of financial interests.--
                    ``(A) In general.--The Secretary may not approve a 
                loan guarantee for a project under this subsection 
                unless the Secretary determines that--
                            ``(i) the terms, conditions, security (if 
                        any), and schedule and amount of repayments 
                        with respect to the loan are sufficient to 
                        protect the financial interests of the United 
                        States and are otherwise reasonable, including 
                        a determination that the rate of interest does 
                        not exceed such percent per annum on the 
                        principal obligation outstanding as the 
                        Secretary determines to be reasonable, taking 
                        into account the range of interest rates 
                        prevailing in the private market for similar 
                        loans and the risks assumed by the United 
                        States, except that the Secretary may not 
                        require as security any center asset that is, 
                        or may be, needed by the center or centers 
                        involved to provide health services;
                            ``(ii) the loan would not be available on 
                        reasonable terms and conditions without the 
                        guarantee under this subsection; and
                            ``(iii) amounts appropriated for the 
                        program under this subsection are sufficient to 
                        provide loan guarantees under this subsection.
                    ``(B) Recovery of payments.--
                            ``(i) In general.--The United States shall 
                        be entitled to recover from the applicant for a 
                        loan guarantee under this subsection the amount 
                        of any payment made pursuant to such guarantee, 
                        unless the Secretary for good cause waives such 
                        right of recovery (subject to appropriations 
                        remaining available to permit such a waiver) 
                        and, upon making any such payment, the United 
                        States shall be subrogated to all of the rights 
                        of the recipient of the payments with respect 
                        to which the guarantee was made. Amounts 
                        recovered under this clause shall be credited 
                        as reimbursements to the financing account of 
                        the program.
                            ``(ii) Modification of terms and 
                        conditions.--To the extent permitted by clause 
                        (iii) and subject to the requirements of 
                        section 504(e) of the Credit Reform Act of 1990 
                        (2 U.S.C. 661c(e)), any terms and conditions 
                        applicable to a loan guarantee under this 
                        subsection (including terms and conditions 
                        imposed under clause (iv)) may be modified or 
                        waived by the Secretary to the extent the 
                        Secretary determines it to be consistent with 
                        the financial interest of the United States.
                            ``(iii) Incontestability.--Any loan 
                        guarantee made by the Secretary under this 
                        subsection shall be incontestable--
                                    ``(I) in the hands of an applicant 
                                on whose behalf such guarantee is made 
                                unless the applicant engaged in fraud 
                                or misrepresentation in securing such 
                                guarantee; and
                                    ``(II) as to any person (or 
                                successor in interest) who makes or 
                                contracts to make a loan to such 
                                applicant in reliance thereon unless 
                                such person (or successor in interest) 
                                engaged in fraud or misrepresentation 
                                in making or contracting to make such 
                                loan.
                            ``(iv) Further terms and conditions.--
                        Guarantees of loans under this subsection shall 
                        be subject to such further terms and conditions 
                        as the Secretary determines to be necessary to 
                        assure that the purposes of this section will 
                        be achieved.
            ``(3) Loan origination fees.--
                    ``(A) In general.--The Secretary shall collect a 
                loan origination fee with respect to loans to be 
                guaranteed under this subsection, except as provided in 
                subparagraph (C).
                    ``(B) Amount.--The amount of a loan origination fee 
                collected by the Secretary under subparagraph (A) shall 
                be equal to the estimated long term cost of the loan 
                guarantees involved to the Federal Government 
                (excluding administrative costs), calculated on a net 
                present value basis, after taking into account any 
                appropriations that may be made for the purpose of 
                offsetting such costs, and in accordance with the 
                criteria used to award loan guarantees under this 
                subsection.
                    ``(C) Waiver.--The Secretary may waive the loan 
                origination fee for a health center applicant who 
                demonstrates to the Secretary that the applicant will 
                be unable to meet the conditions of the loan if the 
                applicant incurs the additional cost of the fee.
            ``(4) Defaults.--
                    ``(A) In general.--Subject to the requirements of 
                the Credit Reform Act of 1990 (2 U.S.C. 661 et seq.), 
                the Secretary may take such action as may be necessary 
                to prevent a default on a loan guaranteed under this 
                subsection, including the waiver of regulatory 
                conditions, deferral of loan payments, renegotiation of 
                loans, and the expenditure of funds for technical and 
                consultative assistance, for the temporary payment of 
                the interest and principal on such a loan, and for 
                other purposes. Any such expenditure made under the 
                preceding sentence on behalf of a health center or 
                centers shall be made under such terms and conditions 
                as the Secretary shall prescribe, including the 
                implementation of such organizational, operational, and 
                financial reforms as the Secretary determines are 
                appropriate and the disclosure of such financial or 
                other information as the Secretary may require to 
                determine the extent of the implementation of such 
                reforms.
                    ``(B) Foreclosure.--The Secretary may take such 
                action, consistent with State law respecting 
                foreclosure procedures and, with respect to reserves 
                required for furnishing services on a prepaid basis, 
                subject to the consent of the affected States, as the 
                Secretary determines appropriate to protect the 
                interest of the United States in the event of a default 
                on a loan guaranteed under this subsection, except that 
                the Secretary may only foreclose on assets offered as 
                security (if any) in accordance with paragraph 
                (2)(A)(i).
            ``(5) Limitation.--Not more than one loan guarantee may be 
        made under this subsection for the same network or plan, except 
        that upon a showing of good cause the Secretary may make 
        additional loan guarantees.
            ``(6) Annual report.--Not later than April 1, 1998, and 
        each April 1 thereafter, the Secretary shall prepare and submit 
        to the appropriate committees of Congress a report concerning 
        loan guarantees provided under this subsection. Such report 
        shall include--
                    ``(A) a description of the number, amount, and use 
                of funds received under each loan guarantee provided 
                under this subsection;
                    ``(B) a description of any defaults with respect to 
                such loans and an analysis of the reasons for such 
                defaults, if any; and
                    ``(C) a description of the steps that may have been 
                taken by the Secretary to assist an entity in avoiding 
                such a default.
            ``(7) Program evaluation.--Not later than June 30, 1999, 
        the Secretary shall prepare and submit to the appropriate 
        committees of Congress a report containing an evaluation of the 
        program authorized under this subsection. Such evaluation shall 
        include a recommendation with respect to whether or not the 
        loan guarantee program under this subsection should be 
        continued and, if so, any modifications that should be made to 
        such program.
            ``(8) Authorization of appropriations.--There are 
        authorized to be appropriated to carry out this subsection such 
        sums as may be necessary.
    ``(e) Operating Grants.--
            ``(1) Authority.--
                    ``(A) In general.--The Secretary may make grants 
                for the costs of the operation of public and nonprofit 
                private health centers that provide health services to 
                medically underserved populations.
                    ``(B) Entities that fail to meet certain 
                requirements.--The Secretary may make grants, for a 
                period of not to exceed 2-years, for the costs of the 
                operation of public and nonprofit private entities 
                which provide health services to medically underserved 
                populations but with respect to which the Secretary is 
                unable to make each of the determinations required by 
                subsection (j)(3).
            ``(2) Use of funds.--The costs for which a grant may be 
        made under subparagraph (A) or (B) of paragraph (1) may include 
        the costs of acquiring and leasing buildings and equipment 
        (including the costs of amortizing the principal of, and paying 
        interest on, loans), and the costs of providing training 
        related to the provision of required primary health services 
        and additional health services and to the management of health 
        center programs.
            ``(3) Construction.--The Secretary may award grants which 
        may be used to pay the costs associated with expanding and 
        modernizing existing buildings or constructing new buildings 
        (including the costs of amortizing the principal of, and paying 
        the interest on, loans) for projects approved prior to October 
        1, 1996.
            ``(4) Limitation.--Not more than two grants may be made 
        under subparagraph (B) of paragraph (1) for the same entity.
            ``(5) Amount.--
                    ``(A) In general.--The amount of any grant made in 
                any fiscal year under paragraph (1) to a health center 
                shall be determined by the Secretary, but may not 
                exceed the amount by which the costs of operation of 
                the center in such fiscal year exceed the total of--
                            ``(i) State, local, and other operational 
                        funding provided to the center; and
                            ``(ii) the fees, premiums, and third-party 
                        reimbursements, which the center may reasonably 
                        be expected to receive for its operations in 
                        such fiscal year.
                    ``(B) Payments.--Payments under grants under 
                subparagraph (A) or (B) of paragraph (1) shall be made 
                in advance or by way of reimbursement and in such 
                installments as the Secretary finds necessary and 
                adjustments may be made for overpayments or 
                underpayments.
                    ``(C) Use of nongrant funds.--Nongrant funds 
                described in clauses (i) and (ii) of subparagraph (A), 
                including any such funds in excess of those originally 
                expected, shall be used as permitted under this 
                section, and may be used for such other purposes as are 
                not specifically prohibited under this section if such 
                use furthers the objectives of the project.
    ``(f) Infant Mortality Grants.--
            ``(1) In general.--The Secretary may make grants to health 
        centers for the purpose of assisting such centers in--
                    ``(A) providing comprehensive health care and 
                support services for the reduction of--
                            ``(i) the incidence of infant mortality; 
                        and
                            ``(ii) morbidity among children who are 
                        less than 3 years of age; and
                    ``(B) developing and coordinating service and 
                referral arrangements between health centers and other 
                entities for the health management of pregnant women 
                and children described in subparagraph (A).
            ``(2) Priority.--In making grants under this subsection the 
        Secretary shall give priority to health centers providing 
        services to any medically underserved population among which 
        there is a substantial incidence of infant mortality or among 
        which there is a significant increase in the incidence of 
        infant mortality.
            ``(3) Requirements.--The Secretary may make a grant under 
        this subsection only if the health center involved agrees 
        that--
                    ``(A) the center will coordinate the provision of 
                services under the grant to each of the recipients of 
                the services;
                    ``(B) such services will be continuous for each 
                such recipient;
                    ``(C) the center will provide follow-up services 
                for individuals who are referred by the center for 
                services described in paragraph (1);
                    ``(D) the grant will be expended to supplement, and 
                not supplant, the expenditures of the center for 
                primary health services (including prenatal care) with 
                respect to the purpose described in this subsection; 
                and
                    ``(E) the center will coordinate the provision of 
                services with other maternal and child health providers 
                operating in the catchment area.
    ``(g) Migratory and Seasonal Agricultural Workers.--
            ``(1) In general.--The Secretary may award grants for the 
        purposes described in subsections (c), (e), and (f) for the 
        planning and delivery of services to a special medically 
        underserved population comprised of--
                    ``(A) migratory agricultural workers, seasonal 
                agricultural workers, and members of the families of 
                such migratory and seasonal agricultural workers who 
                are within a designated catchment area; and
                    ``(B) individuals who have previously been 
                migratory agricultural workers but who no longer meet 
                the requirements of subparagraph (A) of paragraph (3) 
                because of age or disability and members of the 
                families of such individuals who are within such 
                catchment area.
            ``(2) Environmental concerns.--The Secretary may enter into 
        grants or contracts under this subsection with public and 
        private entities to--
                    ``(A) assist the States in the implementation and 
                enforcement of acceptable environmental health 
                standards, including enforcement of standards for 
                sanitation in migratory agricultural worker labor 
                camps, and applicable Federal and State pesticide 
                control standards; and
                    ``(B) conduct projects and studies to assist the 
                several States and entities which have received grants 
                or contracts under this section in the assessment of 
                problems related to camp and field sanitation, exposure 
                to unsafe levels of agricultural chemicals including 
                pesticides, and other environmental health hazards to 
                which migratory agricultural workers and members of 
                their families are exposed.
            ``(3) Definitions.--For purposes of this subsection:
                    ``(A) Migratory agricultural worker.--The term 
                `migratory agricultural worker' means an individual 
                whose principal employment is in agriculture on a 
                seasonal basis, who has been so employed within the 
                last 24 months, and who establishes for the purposes of 
                such employment a temporary abode.
                    ``(B) Seasonal agricultural worker.--The term 
                `seasonal agricultural worker' means an individual 
                whose principal employment is in agriculture on a 
                seasonal basis and who is not a migratory agricultural 
                worker.
                    ``(C) Agriculture.--The term `agriculture' means 
                farming in all its branches, including--
                            ``(i) cultivation and tillage of the soil;
                            ``(ii) the production, cultivation, 
                        growing, and harvesting of any commodity grown 
                        on, in, or as an adjunct to or part of a 
                        commodity grown in or on, the land; and
                            ``(iii) any practice (including preparation 
                        and processing for market and delivery to 
                        storage or to market or to carriers for 
                        transportation to market) performed by a farmer 
                        or on a farm incident to or in conjunction with 
                        an activity described in clause (ii).
    ``(h) Homeless Population.--
            ``(1) In general.--The Secretary may award grants for the 
        purposes described in subsections (c), (e), and (f) for the 
        planning and delivery of services to a special medically 
        underserved population comprised of homeless individuals, 
        including grants for innovative programs that provide outreach 
        and comprehensive primary health services to homeless children 
        and children at risk of homelessness.
            ``(2) Required services.--In addition to required primary 
        health services (as defined in subsection (b)(1)), an entity 
        that receives a grant under this subsection shall be required 
        to provide substance abuse services as a condition of such 
        grant.
            ``(3) Supplement not supplant requirement.--A grant awarded 
        under this subsection shall be expended to supplement, and not 
        supplant, the expenditures of the health center and the value 
        of in kind contributions for the delivery of services to the 
        population described in paragraph (1).
            ``(4) Definitions.--For purposes of this section:
                    ``(A) Homeless individual.--The term `homeless 
                individual' means an individual who lacks housing 
                (without regard to whether the individual is a member 
                of a family), including an individual whose primary 
                residence during the night is a supervised public or 
                private facility that provides temporary living 
                accommodations and an individual who is a resident in 
                transitional housing.
                    ``(B) Substance abuse.--The term `substance abuse' 
                has the same meaning given such term in section 534(4).
                    ``(C) Substance abuse services.--The term 
                `substance abuse services' includes detoxification and 
                residential treatment for substance abuse provided in 
                settings other than hospitals.
    ``(i) Residents of Public Housing.--
            ``(1) In general.--The Secretary may award grants for the 
        purposes described in subsections (c), (e), and (f) for the 
        planning and delivery of services to a special medically 
        underserved population comprised of residents of public housing 
        (such term, for purposes of this subsection, shall have the 
        same meaning given such term in section 3(b)(1) of the United 
        States Housing Act of 1937) and individuals living in areas 
        immediately accessible to such public housing.
            ``(2) Supplement not supplant.--A grant awarded under this 
        subsection shall be expended to supplement, and not supplant, 
        the expenditures of the health center and the value of in kind 
        contributions for the delivery of services to the population 
        described in paragraph (1).
            ``(3) Consultation with residents.--The Secretary may not 
        make a grant under paragraph (1) unless, with respect to the 
        residents of the public housing involved, the applicant for the 
        grant--
                    ``(A) has consulted with the residents in the 
                preparation of the application for the grant; and
                    ``(B) agrees to provide for ongoing consultation 
                with the residents regarding the planning and 
                administration of the program carried out with the 
                grant.
    ``(j) Applications.--
            ``(1) Submission.--No grant may be made under this section 
        unless an application therefore is submitted to, and approved 
        by, the Secretary. Such an application shall be submitted in 
        such form and manner and shall contain such information as the 
        Secretary shall prescribe.
            ``(2) Description of need.--An application for a grant 
        under subparagraph (A) or (B) of subsection (e)(1) for a health 
        center shall include--
                    ``(A) a description of the need for health services 
                in the catchment area of the center;
                    ``(B) a demonstration by the applicant that the 
                area or the population group to be served by the 
                applicant has a shortage of personal health services; 
                and
                    ``(C) a demonstration that the center will be 
                located so that it will provide services to the 
                greatest number of individuals residing in the 
                catchment area or included in such population group.
        Such a demonstration shall be made on the basis of the criteria 
        prescribed by the Secretary under subsection (b)(3) or on any 
        other criteria which the Secretary may prescribe to determine 
        if the area or population group to be served by the applicant 
        has a shortage of personal health services. In considering an 
        application for a grant under subparagraph (A) or (B) of 
        subsection (e)(1), the Secretary may require as a condition to 
        the approval of such application an assurance that the 
        applicant will provide any health service defined under 
        paragraphs (1) and (2) of subsection (b) that the Secretary 
        finds is needed to meet specific health needs of the area to be 
        served by the applicant. Such a finding shall be made in 
        writing and a copy shall be provided to the applicant.
            ``(3) Requirements.--Except as provided in subsection 
        (e)(1)(B), the Secretary may not approve an application for a 
        grant under subparagraph (A) or (B) of subsection (e)(1) unless 
        the Secretary determines that the entity for which the 
        application is submitted is a health center (within the meaning 
        of subsection (a)) and that--
                    ``(A) the required primary health services of the 
                center will be available and accessible in the 
                catchment area of the center promptly, as appropriate, 
                and in a manner which assures continuity;
                    ``(B) the center has made and will continue to make 
                every reasonable effort to establish and maintain 
                collaborative relationships with other health care 
                providers in the catchment area of the center;
                    ``(C) the center will have an ongoing quality 
                improvement system that includes clinical services and 
                management, and that maintains the confidentiality of 
                patient records;
                    ``(D) the center will demonstrate its financial 
                responsibility by the use of such accounting procedures 
                and other requirements as may be prescribed by the 
                Secretary;
                    ``(E) the center--
                            ``(i) has or will have a contractual or 
                        other arrangement with the agency of the State, 
                        in which it provides services, which 
                        administers or supervises the administration of 
                        a State plan approved under title XIX of the 
                        Social Security Act for the payment of all or a 
                        part of the center's costs in providing health 
                        services to persons who are eligible for 
                        medical assistance under such a State plan; or
                            ``(ii) has made or will make every 
                        reasonable effort to enter into such an 
                        arrangement;
                    ``(F) the center has made or will make and will 
                continue to make every reasonable effort to collect 
                appropriate reimbursement for its costs in providing 
                health services to persons who are entitled to 
                insurance benefits under title XVIII of the Social 
                Security Act, to medical assistance under a State plan 
                approved under title XIX of such Act, or to assistance 
                for medical expenses under any other public assistance 
                program or private health insurance program;
                    ``(G) the center--
                            ``(i) has prepared a schedule of fees or 
                        payments for the provision of its services 
                        consistent with locally prevailing rates or 
                        charges and designed to cover its reasonable 
                        costs of operation and has prepared a 
                        corresponding schedule of discounts to be 
                        applied to the payment of such fees or 
                        payments, which discounts are adjusted on the 
                        basis of the patient's ability to pay;
                            ``(ii) has made and will continue to make 
                        every reasonable effort--
                                    ``(I) to secure from patients 
                                payment for services in accordance with 
                                such schedules; and
                                    ``(II) to collect reimbursement for 
                                health services to persons described in 
                                subparagraph (F) on the basis of the 
                                full amount of fees and payments for 
                                such services without application of 
                                any discount; and
                            ``(iii) has submitted to the Secretary such 
                        reports as the Secretary may require to 
                        determine compliance with this subparagraph;
                    ``(H) the center has established a governing board 
                which except in the case of an entity operated by an 
                Indian tribe or tribal or Indian organization under the 
                Indian Self-Determination Act or an urban Indian 
                organization under the Indian Health Care Improvement 
                Act (25 U.S.C. 1651 et seq.)--
                            ``(i) is composed of individuals, a 
                        majority of whom are being served by the center 
                        and who, as a group, represent the individuals 
                        being served by the center;
                            ``(ii) meets at least once a month, selects 
                        the services to be provided by the center, 
                        schedules the hours during which such services 
                        will be provided, approves the center's annual 
                        budget, approves the selection of a director 
                        for the center, and, except in the case of a 
                        governing board of a public center (as defined 
                        in the second sentence of this paragraph), 
                        establishes general policies for the center; 
                        and
                            ``(iii) in the case of an application for a 
                        second or subsequent grant for a public center, 
                        has approved the application or if the 
                        governing body has not approved the 
                        application, the failure of the governing body 
                        to approve the application was unreasonable;
                except that, upon a showing of good cause the Secretary 
                shall waive, for the length of the project period, all 
                or part of the requirements of this subparagraph in the 
                case of a health center that receives a grant pursuant 
                to subsection (g), (h), (i), or (p);
                    ``(I) the center has developed--
                            ``(i) an overall plan and budget that meets 
                        the requirements of the Secretary; and
                            ``(ii) an effective procedure for compiling 
                        and reporting to the Secretary such statistics 
                        and other information as the Secretary may 
                        require relating to--
                                    ``(I) the costs of its operations;
                                    ``(II) the patterns of use of its 
                                services;
                                    ``(III) the availability, 
                                accessibility, and acceptability of its 
                                services; and
                                    ``(IV) such other matters relating 
                                to operations of the applicant as the 
                                Secretary may require;
                    ``(J) the center will review periodically its 
                catchment area to--
                            ``(i) ensure that the size of such area is 
                        such that the services to be provided through 
                        the center (including any satellite) are 
                        available and accessible to the residents of 
                        the area promptly and as appropriate;
                            ``(ii) ensure that the boundaries of such 
                        area conform, to the extent practicable, to 
                        relevant boundaries of political subdivisions, 
                        school districts, and Federal and State health 
                        and social service programs; and
                            ``(iii) ensure that the boundaries of such 
                        area eliminate, to the extent possible, 
                        barriers to access to the services of the 
                        center, including barriers resulting from the 
                        area's physical characteristics, its 
                        residential patterns, its economic and social 
                        grouping, and available transportation;
                    ``(K) in the case of a center which serves a 
                population including a substantial proportion of 
                individuals of limited English-speaking ability, the 
                center has--
                            ``(i) developed a plan and made 
                        arrangements responsive to the needs of such 
                        population for providing services to the extent 
                        practicable in the language and cultural 
                        context most appropriate to such individuals; 
                        and
                            ``(ii) identified an individual on its 
                        staff who is fluent in both that language and 
                        in English and whose responsibilities shall 
                        include providing guidance to such individuals 
                        and to appropriate staff members with respect 
                        to cultural sensitivities and bridging 
                        linguistic and cultural differences; and
                    ``(L) the center, has developed an ongoing referral 
                relationship with one or more hospitals.
        For purposes of subparagraph (H), the term `public center' 
        means a health center funded (or to be funded) through a grant 
        under this section to a public agency.
            ``(4) Approval of new or expanded service applications.--
        The Secretary shall approve applications for grants under 
        subparagraph (A) or (B) of subsection (e)(1) for health centers 
        which--
                    ``(A) have not received a previous grant under such 
                subsection; or
                    ``(B) have applied for such a grant to expand their 
                services;
        in such a manner that the ratio of the medically underserved 
        populations in rural areas which may be expected to use the 
        services provided by such centers to the medically underserved 
        populations in urban areas which may be expected to use the 
        services provided by such centers is not less than two to three 
        or greater than three to two.
    ``(k) Technical and Other Assistance.--The Secretary may provide 
(either through the Department of Health and Human Services or by grant 
or contract) all necessary technical and other nonfinancial assistance 
(including fiscal and program management assistance and training in 
such management) to any public or private nonprofit entity to assist 
entities in developing plans for, or operating as, health centers, and 
in meeting the requirements of subsection (j)(2).
    ``(l) Authorization of Appropriations.--
            ``(1) In general.--For the purpose of carrying out this 
        section, in addition to the amounts authorized to be 
        appropriated under subsection (d), there are authorized to be 
        appropriated $802,124,000 for fiscal year 1997, and such sums 
        as may be necessary for each of the fiscal years 1998 through 
        2001.
            ``(2) Special provisions.--
                    ``(A) Public centers.--The Secretary may not expend 
                in any fiscal year, for grants under this section to 
                public centers (as defined in the second sentence of 
                subsection (j)(3)) the governing boards of which (as 
                described in subsection (j)(3)(G)(ii)) do not establish 
                general policies for such centers, an amount which 
                exceeds 5 percent of the amounts appropriated under 
                this section for that fiscal year. For purposes of 
                applying the preceding sentence, the term `public 
                centers' shall not include health centers that receive 
                grants pursuant to subsection (h) or (i).
                    ``(B) Distribution of grants.--
                            ``(i) Fiscal year 1997.--For fiscal year 
                        1997, the Secretary, in awarding grants under 
                        this section shall ensure that the amounts made 
                        available under each of subsections (g), (h), 
                        and (i) in such fiscal year bears the same 
                        relationship to the total amount appropriated 
                        for such fiscal year under paragraph (1) as the 
                        amounts appropriated for fiscal year 1996 under 
                        each of sections 329, 340, and 340A (as such 
                        sections existed one day prior to the date of 
                        enactment of this section) bears to the total 
                        amount appropriated under sections 329, 330, 
                        340, and 340A (as such sections existed one day 
                        prior to the date of enactment of this section) 
                        for such fiscal year.
                            ``(ii) Fiscal years 1998 and 1999.--For 
                        each of the fiscal years 1998 and 1999, the 
                        Secretary, in awarding grants under this 
                        section shall ensure that the proportion of the 
                        amounts made available under each of 
                        subsections (g), (h), and (i) is equal to the 
                        proportion of amounts made available under each 
                        such subsection for the previous fiscal year, 
                        as such amounts relate to the total amounts 
                        appropriated for the previous fiscal year 
                        involved, increased or decreased by not more 
                        than 10 percent.
            ``(3) Funding report.--The Secretary shall annually prepare 
        and submit to the appropriate committees of Congress a report 
        concerning the distribution of funds under this section that 
        are provided to meet the health care needs of medically 
        underserved populations, including the homeless, residents of 
        public housing, and migratory and seasonal agricultural 
        workers, and the appropriateness of the delivery systems 
        involved in responding to the needs of the particular 
        populations. Such report shall include an assessment of the 
        relative health care access needs of the targeted populations 
        and the rationale for any substantial changes in the 
        distribution of funds.
    ``(m) Memorandum of Agreement.--In carrying out this section, the 
Secretary may enter into a memorandum of agreement with a State. Such 
memorandum may include, where appropriate, provisions permitting such 
State to--
            ``(1) analyze the need for primary health services for 
        medically underserved populations within such State;
            ``(2) assist in the planning and development of new health 
        centers;
            ``(3) review and comment upon annual program plans and 
        budgets of health centers, including comments upon allocations 
        of health care resources in the State;
            ``(4) assist health centers in the development of clinical 
        practices and fiscal and administrative systems through a 
        technical assistance plan which is responsive to the requests 
        of health centers; and
            ``(5) share information and data relevant to the operation 
        of new and existing health centers.
    ``(n) Records.--
            ``(1) In general.--Each entity which receives a grant under 
        subsection (e) shall establish and maintain such records as the 
        Secretary shall require.
            ``(2) Availability.--Each entity which is required to 
        establish and maintain records under this subsection shall make 
        such books, documents, papers, and records available to the 
        Secretary or the Comptroller General of the United States, or 
        any of their duly authorized representatives, for examination, 
        copying or mechanical reproduction on or off the premises of 
        such entity upon a reasonable request therefore. The Secretary 
        and the Comptroller General of the United States, or any of 
        their duly authorized representatives, shall have the authority 
        to conduct such examination, copying, and reproduction.
    ``(o) Delegation of Authority.--The Secretary may delegate the 
authority to administer the programs authorized by this section to any 
office, except that the authority to enter into, modify, or issue 
approvals with respect to grants or contracts may be delegated only 
within the central office of the Health Resources and Services 
Administration.
    ``(p) Special Consideration.--In making grants under this section, 
the Secretary shall give special consideration to the unique needs of 
sparsely populated rural areas, including giving priority in the 
awarding of grants for new health centers under subsections (c) and 
(e), and the granting of waivers as appropriate and permitted under 
subsections (b)(1)(B)(i) and (j)(3)(G).
    ``(q) Audits.--
            ``(1) In general.--Each entity which receives a grant under 
        this section shall provide for an independent annual financial 
        audit of any books, accounts, financial records, files, and 
        other papers and property which relate to the disposition or 
        use of the funds received under such grant and such other funds 
        received by or allocated to the project for which such grant 
        was made. For purposes of assuring accurate, current, and 
        complete disclosure of the disposition or use of the funds 
        received, each such audit shall be conducted in accordance with 
        generally accepted accounting principles. Each audit shall 
        evaluate--
                    ``(A) the entity's implementation of the guidelines 
                established by the Secretary respecting cost 
                accounting,
                    ``(B) the processes used by the entity to meet the 
                financial and program reporting requirements of the 
                Secretary, and
                    ``(C) the billing and collection procedures of the 
                entity and the relation of the procedures to its fee 
                schedule and schedule of discounts and to the 
                availability of health insurance and public programs to 
                pay for the health services it provides.
        A report of each such audit shall be filed with the Secretary 
        at such time and in such manner as the Secretary may require.
            ``(2) Records.--Each entity which receives a grant under 
        this section shall establish and maintain such records as the 
        Secretary shall by regulation require to facilitate the audit 
        required by paragraph (1). The Secretary may specify by 
        regulation the form and manner in which such records shall be 
        established and maintained.
            ``(3) Availability of records.--Each entity which is 
        required to establish and maintain records or to provide for 
        and audit under this subsection shall make such books, 
        documents, papers, and records available to the Secretary or 
        the Comptroller General of the United States, or any of their 
        duly authorized representatives, for examination, copying or 
        mechanical reproduction on or off the premises of such entity 
        upon a reasonable request therefore. The Secretary and the 
        Comptroller General of the United States, or any of their duly 
        authorized representatives, shall have the authority to conduct 
        such examination, copying, and reproduction.
            ``(4) Waiver.--The Secretary may, under appropriate 
        circumstances, waive the application of all or part of the 
        requirements of this subsection with respect to an entity.''.

SEC. 3. RURAL HEALTH OUTREACH, NETWORK DEVELOPMENT, AND TELEMEDICINE 
              GRANT PROGRAM.

    (a) In General.--Subpart I of part D of title III of the Public 
Health Service Act (42 U.S.C. 254b et seq.) (as amended by section 2) 
is further amended by adding at the end thereof the following new 
section:

``SEC. 330A. RURAL HEALTH OUTREACH, NETWORK DEVELOPMENT, AND 
              TELEMEDICINE GRANT PROGRAM.

    ``(a) Administration.--The rural health services outreach 
demonstration grant program established under section 301 shall be 
administered by the Office of Rural Health Policy (of the Health 
Resources and Services Administration), in consultation with State 
rural health offices or other appropriate State governmental entities.
    ``(b) Grants.--Under the program referred to in subsection (a), the 
Secretary, acting through the Director of the Office of Rural Health 
Policy, may award grants to expand access to, coordinate, restrain the 
cost of, and improve the quality of essential health care services, 
including preventive and emergency services, through the development of 
integrated health care delivery systems or networks in rural areas and 
regions.
    ``(c) Eligible Networks.--
            ``(1) Outreach networks.--To be eligible to receive a grant 
        under this section, an entity shall--
                    ``(A) be a rural public or nonprofit private entity 
                that is or represents a network or potential network 
                that includes three or more health care providers or 
                other entities that provide or support the delivery of 
                health care services; and
                    ``(B) in consultation with the State office of 
                rural health or other appropriate State entity, prepare 
                and submit to the Secretary an application, at such 
                time, in such manner, and containing such information 
                as the Secretary may require, including--
                            ``(i) a description of the activities which 
                        the applicant intends to carry out using 
                        amounts provided under the grant;
                            ``(ii) a plan for continuing the project 
                        after Federal support is ended;
                            ``(iii) a description of the manner in 
                        which the activities funded under the grant 
                        will meet health care needs of underserved 
                        rural populations within the State; and
                            ``(iv) a description of how the local 
                        community or region to be served by the network 
                        or proposed network will be involved in the 
                        development and ongoing operations of the 
                        network.
            ``(2) For-profit entities.--An eligible network may include 
        for-profit entities so long as the network grantee is a 
        nonprofit entity.
            ``(3) Telemedicine networks.--
                    ``(A) In general.--An entity that is a health care 
                provider and a member of an existing or proposed 
                telemedicine network, or an entity that is a consortium 
                of health care providers that are members of an 
                existing or proposed telemedicine network shall be 
                eligible for a grant under this section.
                    ``(B) Requirement.--A telemedicine network referred 
                to in subparagraph (A) shall, at a minimum, be composed 
                of--
                            ``(i) a multispecialty entity that is 
                        located in an urban or rural area, which can 
                        provide 24-hour a day access to a range of 
                        specialty care; and
                            ``(ii) at least two rural health care 
                        facilities, which may include rural hospitals, 
                        rural physician offices, rural health clinics, 
                        rural community health clinics, and rural 
                        nursing homes.
    ``(d) Preference.--In awarding grants under this section, the 
Secretary shall give preference to applicant networks that include--
            ``(1) a majority of the health care providers serving in 
        the area or region to be served by the network;
            ``(2) any federally qualified health centers, rural health 
        clinics, and local public health departments serving in the 
        area or region;
            ``(3) outpatient mental health providers serving in the 
        area or region; or
            ``(4) appropriate social service providers, such as 
        agencies on aging, school systems, and providers under the 
        women, infants, and children program, to improve access to and 
        coordination of health care services.
    ``(e) Use of Funds.--
            ``(1) In general.--Amounts provided under grants awarded 
        under this section shall be used--
                    ``(A) for the planning and development of 
                integrated self-sustaining health care networks; and
                    ``(B) for the initial provision of services.
            ``(2) Expenditures in rural areas.--
                    ``(A) In general.--In awarding a grant under this 
                section, the Secretary shall ensure that not less than 
                50 percent of the grant award is expended in a rural 
                area or to provide services to residents of rural 
                areas.
                    ``(B) Telemedicine networks.--An entity described 
                in subsection (c)(3) may not use in excess of--
                            ``(i) 40 percent of the amounts provided 
                        under a grant under this section to carry out 
                        activities under paragraph (3)(A)(iii); and
                            ``(ii) 20 percent of the amounts provided 
                        under a grant under this section to pay for the 
                        indirect costs associated with carrying out the 
                        purposes of such grant.
            ``(3) Telemedicine networks.--
                    ``(A) In general.--An entity described in 
                subsection (c)(3), may use amounts provided under a 
                grant under this section to--
                            ``(i) demonstrate the use of telemedicine 
                        in facilitating the development of rural health 
                        care networks and for improving access to 
                        health care services for rural citizens;
                            ``(ii) provide a baseline of information 
                        for a systematic evaluation of telemedicine 
                        systems serving rural areas;
                            ``(iii) purchase or lease and install 
                        equipment; and
                            ``(iv) operate the telemedicine system and 
                        evaluate the telemedicine system.
                    ``(B) Limitations.--An entity described in 
                subsection (c)(3), may not use amounts provided under a 
                grant under this section--
                            ``(i) to build or acquire real property;
                            ``(ii) purchase or install transmission 
                        equipment (such as laying cable or telephone 
                        lines, microwave towers, satellite dishes, 
                        amplifiers, and digital switching equipment); 
                        or
                            ``(iii) for construction, except that such 
                        funds may be expended for minor renovations 
                        relating to the installation of equipment;
    ``(f) Term of Grants.--Funding may not be provided to a network 
under this section for in excess of a 3-year period.
    ``(g) Authorization of Appropriations.--For the purpose of carrying 
out this section there are authorized to be appropriated $36,000,000 
for fiscal year 1997, and such sums as may be necessary for each of the 
fiscal years 1998 through 2001.''.
    (b) Transition.--The Secretary of Health and Human Services shall 
ensure the continued funding of grants made, or contracts or 
cooperative agreements entered into, under subpart I of part D of title 
III of the Public Health Service Act (42 U.S.C. 254b et seq.) (as such 
subpart existed on the day prior to the date of enactment of this Act), 
until the expiration of the grant period or the term of the contract or 
cooperative agreement. Such funding shall be continued under the same 
terms and conditions as were in effect on the date on which the grant, 
contract or cooperative agreement was awarded, subject to the 
availability of appropriations.

SEC. 4. TECHNICAL AND CONFORMING AMENDMENTS.

    (a) In General.--The Public Health Service Act is amended--
            (1) in section 224(g)(4) (42 U.S.C. 233(g)(4)), by striking 
        ``under'' and all that follows through the end thereof and 
        inserting ``under section 330.'';
            (2) in section 340C(a)(2) (42 U.S.C. 256c) by striking 
        ``under'' and all that follows through the end thereof and 
        inserting ``with assistance provided under section 330.''; and
            (3) by repealing subparts V and VI of part D of title III 
        (42 U.S.C. 256 et seq.).
    (b) Social Security Act.--The Social Security Act is amended--
            (1) in clauses (i) and (ii)(I) of section 1861(aa)(4)(A) 
        (42 U.S.C. 1395x(aa)(4)(A)(i) and (ii)(I)) by striking 
        ``section 329, 330, or 340'' and inserting ``section 330 (other 
        than subsection (h))''; and
            (2) in clauses (i) and (ii)(II) of section 1905(l)(2)(B) 
        (42 U.S.C. 1396d(l)(2)(B)(i) and (ii)(II)) by striking 
        ``section 329, 330, 340, or 340A'' and inserting ``section 
        330''.
    (c) References.--Whenever any reference is made in any provision of 
law, regulation, rule, record, or document to a community health 
center, migrant health center, public housing health center, or 
homeless health center, such reference shall be considered a reference 
to a health center.
    (d) FTCA Clarification.--For purposes of section 224(k)(3) of the 
Public Health Service Act (42 U.S.C. 233(k)(3)), transfers from the 
fund described in such section for fiscal year 1996 shall be deemed to 
have occurred prior to December 31, 1995.
    (e) Additional Amendments.--After consultation with the appropriate 
committees of the Congress, the Secretary of Health and Human Services 
shall prepare and submit to the Congress a legislative proposal in the 
form of an implementing bill containing technical and conforming 
amendments to reflect the changes made by this Act.

SEC. 5. EFFECTIVE DATE.

    This Act and the amendments made by this Act shall become effective 
on October 1, 1997.

            Passed the Senate September 20, 1996.

            Attest:

                                                             Secretary.
104th CONGRESS

  2d Session

                                S. 1044

_______________________________________________________________________

                                 AN ACT

To amend title III of the Public Health Service Act to consolidate and 
   reauthorize provisions relating to health centers, and for other 
                               purposes.